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FLIPCHART FOR CLIENT EDUCATION

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Risk Factors for Fertility Problems

This tool can help you: • Provide information about risk factors for impaired fertility • Provide tailored guidance to the client about what steps they can take to protect their future fertility potential • Engage in open discussion with and to provide support for clients

It can be used to help clients with different needs: • Currently trying to get pregnant • Future wish to get pregnant

This tool has instructions for the PROVIDER on one side and information for the CLIENT on the other side Say to client: • If you’re planning to have children now or in the future you need to start taking care of your body right now. • I will help you find out what you can do for your fertility. • We can do this whether you’re currently trying to get pregnant or not.

CLIENT PAGE

PROVIDER PAGE

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Using this flipchart, we can help you: • Assess your risk for infertility

• Help you think about how lifestyle choices affect fertility • Assist in helping you decide when/if to consult with your provider about fertility

Please tell me about: • Yourself

• Your needs • Your questions

We hope to provide you with privacy and confidentiality

• Greet client with warmth and respect. • Thank client for coming. • Point to this flipchart. Explain that it will help both you and the client. • Invite client to talk and ask questions. • Make clear that you want to listen. Explain that you need the client to speak openly so you can help. • Is meeting space private? • Explain that this meeting will be confidential: “What you say will not be told to others.”

NEXT MOVE: When the client is comfortable and ready to talk, begin the questions. Go to the next page.

Please tell me about:

We hope to provide you with privacy and confidentiality

Â© SCARLET DESIGN INTERNATIONAL LTD 2016

Yourself Your needs Your questions

• Explain to the client how the process of conception occurs • Sexual intercourse • Sperm-egg • Fertile window (point to calendar on their side of the flip chart)

• For a woman to become pregnant she has to have unprotected sex with her husband • The timing of the intercourse should be within a certain time of her monthly cycle (point to the wheel) • A woman is most fertile on the day of ovulation and 5 days before it • The day of ovulation is usually around day 14 of a 28 day cycle (14 days after the first day of your period)

• Ask: • How old are you? Have you been trying to get pregnant? How long? (make a note on the score sheet) • B  34 years or younger and trying for 0-12 months • B  Over 34 years and trying for 0-6 months • R  Over 34 years and trying for 6 months or more • R  Any age and trying for more than 12 months

• Note: If the client is not trying to get pregnant, chose age group and consider them trying for under 6 months in the ‘About trying’ section. • If the client is not clear about her age ask probing questions like when did you finish school, to help you ascertain her age • Age: explain that female fertility declines after 34 years of age (reproductive window) • Time trying: explain that after 12 months trying all couples must seek medical advice 4A

How old are you? Are you trying to have a baby? How long have you been trying?

I want to ask you some questions about your Period: (make a note on the score sheet)

O ď‚° Do you have severe period pains?

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O  I s your period unpredictable, comes more than 5 days earlier or later than expected (not using contraception)?

If the client not sure can ask probing questions: • What is your bleeding like? • Do you sometimes get bleeding in between? • What is your interval period? • Have you always experienced this type of bleeding pattern? (Does the client understand the menstrual cycle and what is bleeding and what isn’t?)

OD oes your cycle last less than 21 days (not using contraception)? OD oes your cycle last more than 35 days (not using contraception)?

If the client is not sure you can ask probing questions: • Do you have less than 21 days between bleeding when not using a contraceptive? • Do you have more than 35 days between bleeding when not using a contraceptive? • How often do you menstruate when not using a contraceptive? • Is this typical for you?

RD o you have a period?

Probing: • Explore the length of time that the client has not been menstruating • If 2-3 months, probe to see if they may be pregnant

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Oď‚°H ave you had pelvic surgery? (Any surgery below the naval including C-section and non-reproductive surgery). Where were you cut and why?

OH as a doctor told you that you have endometriosis or PCOS? (explain what these are)

Probing: • Explore the length of time that the client has not been menstruating • If 2-3 months, probe to see if they may be pregnant

10A

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OH as a doctor told you that you have pelvic inflammatory disease (PID), now or in the past?

Probing: • I have pain in my lower abdomen during sex or associated with periods where I don’t normally have pain. (Ascertain if client suffers from PID) • Do you have symptoms of PID? 1. Pain in the pelvis 2. Pain during intercourse 3. Fever 4. Vaginal discharge that smells bad 5. Irregular menstrual periods 6. Pain during urination

11A

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Certain medical conditions and/or their treatments could potentially hinder your ability to become pregnant: • Diabetes: can delay first period and lead to early menopause and can cause period problems (The reproductive period of diabetic women may be reduced due to delayed menarche and premature menopause. During the reproductive years, diabetes has been associated with menstrual abnormalities) • Kidney disease: can cause less ovulation (Impaired ovulation, but once a new kidney is implanted can regain functioning) • Cancer: chemo and radiation of the pelvic area cause less ovulation (accelerated depletion of ovarian reserve). • Thyroid Disease: can cause period (menstrual) problems • Lupus: the condition or its treatment can lead to less ovulation (Premature ovarian failure (POI), caused by autoimmune causes or drug induced)

RECOMMENDATION If you have been told by a doctor that you have any of these conditions talk to the diagnosing physician about the side effects and impact on fertility

12A

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Talk to your doctor

12B

Are you and your partner related? (Or) Do you plan to marry a relative? Did you have genetic counselling/testing before you got married? Or at later time? Explain that it can potentially can increase number of pregnancies but in the long run overall fertility (number of live births is reduced) RECOMMENDATIONS Although marrying a close relative will not reduce chance of getting pregnant in the long run it can lead to having less children. Consider this before marriage and if already married to cousin (blood relative) then consider genetic testing to rule out genetic abnormalities (make referral to appropriate genetic counselling facility)

13A

Think about this...

13B

Ask if she has undergone FGC and what type (this needs probing) Probing: • If client says yes, ascertain type by explaining what the different types are: • Type I, SUNNA: partial or total removal of the clitoris • Type II, INTERMEDIATE: partial or total removal of the clitoris and labia minora (“the lips” that surround the vagina) with or without removal or the labia majora • Type III, PHARAONIC: narrowing of the vaginal opening formed by cutting and stitching the labia minora or majora with or without removal of the clitoris • Type IV, OTHER : all other harmful procedures to the genital for non-medical reasons

RECOMMENDATION Although doesn’t appear to reduce chance to become pregnant, potentially it can reduce live birth rate which is likely due to labour complications which can increase morbidity and mortality of mother and child. Try to avoid FGC in future generations. If already infibulated (type III) consider deinfibulation before pregnancy (consult with local OBGYN), and consider not having reinfibulation after giving birth.

14A

Have you undergone FGC?

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What type was it?

14B

• Have you had TB in the past? • TB in the chest can lead to TB in the reproductive organs, known as GTB. • GTB can decrease your ability to get pregnant (damage ovaries, tubes and endometrium disrupt ovulation, fertilization and implantation). • If you have pain below the naval at times other than during your period, or you have no period, ask your doctor to check for TB.

RECOMMENDATION If you have pain below the naval at times other than during your period or you have no period ask your doctor to check for TB. Get regular screening for TB to help prevent GTB from developing

15A

Active TB • Coughing • Low fever • Tiredness

GTB • Pelvic pain • Irregular or ‘no period’ 15B

• Have you been tested for HIV? • Have you been counselled for HIV? • HIV can potentially reduced ability to get pregnant

RECOMMENDATION Approach this topic with great sensitivity, give information about the risk to fertility of having HIV. Advise them that they could consider getting tested for HIV if there is a risk. DO NOT use the words SEX or PARTNER.

16A

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â€˘ Has a doctor told you that you have bacterial vaginosis? â€˘ Do you have thin, grey, white or green vaginal discharge with fishy odour?

RECOMMENDATION Get tested if there is discharge (fishy odour) and try to avoid (decrease) douching, having sex with multiple partners, smoking, and using IUD.

17A

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Each question in the lifestyle section should be given to the woman and then repeated with her husband (except overweight). I want to ask you some questions about your lifestyle (daily habits): YD o you smoking frequently (>10 cigarettes per day)? Probing: • How many (cigarettes) do they smoke per day? • Do you smoke argela (insert local alternative for water-pipe), chew tobacco or have other smoking ways? (DO NOT TELL THEM THAT 10 IS A LIMIT) • If you can ascertain that the client smokes more than 10 cigarettes per day, answer YES to this question.

18A

18B

YD o you drink more than 14 units alcohol per week (explain what that would look like)?

Probing: • How much do they drink? (1 unit = a small glass of wine, ½ pint of beer, a single measure of a spirit). • What do you drink (INSERT ADAPTATION OF LOCAL ALCOHOLIC BEVERAGES) • If you can ascertain, they drink more than 14 units, answer YES to this question.

19A

19B

YD o you drink more than 7 units caffeine per day (explain what that would look like)?

Probing: • What do you drink? Do you drink Coke? Coffee? Tea? (INSERT ADAPTATION: Local caffeine? Coffee? Tea? Energy drinks?) • How much do you drink? (Figure out units) • If you ascertain that they consume more than 7 units, answer yes to this question. (1 unit – a cup of coffee, ½ unit – a cup of tea or a can of soft drink such as cola)

20A

20B

YD o you smoke marijuana (Hasheesh, or local equivalent) frequently (>4 time per week)?

Probing: • If client says yes, ascertain how often? • If more than 4 times a week, answer yes to this question

21A

21B

YD o you feel like you can’t cope with the stress you’re currently experiencing? Probing woman: • Are you experiencing any financial difficulties? • Do you have any marital stress? • How safe to you feel in you daily life? • Explore any domestic violence or sexual abuse by partner • Do you get the kind of support from others that you need? • Do you fear or blame yourself for any reason which affects your sexual behaviour? • How often do you have negative feelings such as blue mood, despair, anxiety, depression • If yes to any then ask if they feel like they can’t cope with the stress caused by the situation

Probing man: • Are you having any troubles at work? • Do you have any marital problems? • Do you have any financial troubles? • Do you have problems or are unsatisfied with your sexual life? • Explore any domestic violence or sexual abuse by partner • Do you get the kind of support from others that you need? • Do you fear or blame yourself for any reason which affects your sexual behaviour? • How often do you have negative feelings such as blue mood, despair, anxiety, depression

22A

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Yď‚°U nprotected sex with multiple partners If the woman appears conservative/religious or the husband is present then instead of asking as questions can just give as advice. Having sex with multiple partners without condoms can increase risk for fertility problems. Also need to state that the risk is the same if either partner is engaging in sex with multiple partners not just the women.

RECOMMENDATION Approach this topic with great sensitivity and DO NOT ask this as a question, give information about the risk to fertility of having intimate relationships without using protection that applies to both the husband and wife. DO NOT use the words SEX or PARTNER.

23A

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OH as a doctor told you that you have an STI at any time?

Probing: 1. I have had a vaginal infection? 2. I have been treated with a medicine for a vaginal infection? • Has your husband/wife ever given you an infection in your genital area? • If yes, how often do you get an infection (Does the client understand the difference between an STI and a reproductive tract infection or other infections?)

24A

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OA re you more than 13kg (28 lb, 2 stone) overweight?

Probing: © SCARLET DESIGN INTERNATIONAL LTD 2016

• Does the client have a scale? • If a scale is available ascertain BMI using the chart on the right. If a scale is not available then try to visually ascertain if the client is more than 13 kilos overweight, if appears to be then ANSWER YES.

25A

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RH ave you ever used class A drugs (heroin, cocaine, ecstasy)? RA re you currently taking anabolic steroids (for non-medical uses)?

Probing: • What local drugs have you used?

26A

26B

RD o you have undescended testicles? (if husband is present) RD oes your husband have undescended testicles?

Probing: • Have you ever had surgery on your testicles because you only have one testicle? • When did you have your surgery?

27A

RD id you get mumps any time after puberty? (if husband is present) RD id your husband get mumps any time after puberty?

Probing: • Since his voice changed, he has had swelling in his neck and his testicles. • Did he have swelling in his neck and testicles at the same time?

28A

Based on the score sheet give the according advice and hand over the score sheet to the client (flip client side to the appropriate guidance) BLUE

YELLOW

ORANGE

RED

You don’t have any of the risk factors but keep monitoring your situation because it may change and female fertility decreases after the age of 34 years.

You should consider changing your lifestyle habits, all these factors have an impact (can affect) on your fertility, whether or not you’re trying to conceive (get pregnant). If you’re not trying to get pregnant you should know that (just remember that) female fertility decreases after the age of 34 years.

These factors maybe important to your fertility. Consider seeking medical advice if you’re trying to get pregnant. Your doctor may be able to give you guidance and recommend any action if needed. If you’re not trying to get pregnant you should know that (just remember that) female fertility decreases after the age of 34 years.

If you’re trying to get pregnant, you need to go and see your doctor for further investigation about you’re situation. Drug and anabolic steroid use for non-medical reasons reduces fertility and you should consider changing these lifestyle habits. If you’re not trying to get pregnant you should know that (just remember that) female fertility decreases after the age of 34 years.

29A

? 29B

Your score was Blue This means that: You donâ€™t have any of the risk factors but keep monitoring your situation because it may change and female fertility decreases after the age of 34 years.

30A

Your score was Blue

Just keep checking your status

30B

Your score was Yellow This means that: You should consider changing your lifestyle habits, all these factors have an impact (can affect) on your fertility, whether or not youâ€™re trying to conceive (get pregnant). If youâ€™re not trying to get pregnant you should know that (just remember that) female fertility decreases after the age of 34 years.

31A

Your score was Yellow Think about changing your lifestyle habits

31B

Your score was Orange This means that: These factors maybe important to your fertility. Consider seeking medical advice if youâ€™re trying to get pregnant. Your doctor may be able to give you guidance and recommend any action if needed. If youâ€™re not trying to get pregnant you should know that (just remember that) female fertility decreases after the age of 34 years.

32A

Your score was Orange

Think about talking to a doctor

32B

Your score was Red This means that: If you’re trying to get pregnant, you need to go and see your doctor for further investigation about you’re situation. Drug and anabolic steroid use for nonmedical reasons reduces fertility and you should consider changing these lifestyle habits. If you’re not trying to get pregnant you should know that (just remember that) female fertility decreases after the age of 34 years.

33A

Your score was Red If you’re trying to get pregnant, you need to go and see your doctor to better understand your situation

HEALTH CENTRE

33B

• Do you have any other questions? • Was there something you didn’t understand that you would like me to go over again? • Are there any other issues you would like to ask me about? • Thank you for taking the time to listen and please come back at anytime if you have more questions, want more information or support.

34A

Do you have any questions?

Come back any time...

34B